This week’s three new things include:
- A new supplement that may help brain health and mental illness: l-theanine
- A poor comparison between rapid cycling bipolar disorder and the financial markets
- A new discussion of antipsychiatry
1. New to Me: L-Theanine as an Antidepressant
Maurya, a commenter, asked if I knew anything about l-theanine. Well, I didn’t. Every once in a while even I run across something of which I haven’t heard.
So, for those of you in my boat, here’s a bit about l-theanine:
- L-theanine is derived from green tea although we’re not sure of the best way to extract it.
- L-theanine has been studied on mice and seems to exert antipsychotic- or even antidepressant-like qualities.
- L-theanine is a glutamate derivative and loyal readers will know that I think glutamate will be a big player in mental illness treatment in the next few years. (N-acetylcysteine (NAC) also works with glutamate.)
- There is very little conclusive research on l-theanine, we really just have ideas about what it does; it may possibly be a stress-reducer
- L-theanine may improve cognitive impairment (a human study)
As always, as this is a supplement it is not FDA-controlled and there is no guarantee as to what you will get in the bottle and you should never take any supplement without first checking with your doctor.
More studies on l-theanine can be found here.
I’m a writer so questionable metaphors irk me. And rapid cycling bipolar disorder as a metaphor for the financial marketplace? Really? That’s a whole new level of irk.
If you really want to make that comparison then the bulk of the article should be on the markets and not mental illness, and not the other way around like Lloyd I. Sederer M. D. did in Rapid Cycling Bipolar Disorder: In the Office and On ‘The Street.’
Comments of Mental Illness Stigma
All this poorly-written article did was confuse people and elicit a bunch of anti-bipolar comments like:
“The foundation of the Bi-Polar epidemic is based in suppressed biochemistry, outdated understanding of genetics and a complete misunderstanding of our true spiritual nature.”
“So how exactly is this different from saying some people dramatically over-react to external circumstances?
Sorry folks, but this one goes into the notebook for the next philosophical discussion of “medicalization” as a way of discussing deviance.”
Seems to me he just wanted to use mental illness as an eyeball-grabber, tricking readers onto a topic they would never otherwise read – with the extra bonus of eliciting remarks of stigma.
3. What I Find Interesting – New Discussion of Antipsychiatry
As you might know, I’m not a fan of antipsychiatry folks. I have written a lot on this topic and I’m sure I will write much more in times to come. But I can across this article, Getting It From Both Sides: Foundational and Antifoundational Critiques of Psychiatry which has an interesting discussion of antipsychiatry viewpoints.
Two Sides to Antipsychiatry
It astutely notes there are two sides of antipsychiatry – those who feel that nothing can be defined and thus no mental illness can be defined; and those who feel illness is rigidly defined and mental illness doesn’t meet that definition.
Both sides, as the author says,
“. . . have had the effect of discrediting and marginalizing psychiatry and of delegitimizing psychiatric diagnosis and nosology.”
It’s a very intelligent view of antipsychiatry criticism that is elevated far beyond what we normally see online. Check it out.
Until next week: Smarter and Better.
I try not to give medical advice here because I am not a doctor. But so many people ask me about this I felt I had to address getting off antidepressants without withdrawal. So many people with bipolar disorder (depression and others) need information about getting off psych meds and they are not getting it from their doctors.
This is the first in a three-part series:
- When to Stop Antidepressants in Bipolar Disorder
- How to Stop Antidepressants in Bipolar Disorder While Minimizing Withdrawal
- How to Stop Taking venlafaxine (Effexor) and Desvenlafaxine (Pristiq) – as they are particularly nasty to get off
This is an informational article only and should not be considered a recommendation. Talk to your doctor before any and all changes to your treatment. I’m not kidding about this.
Bipolars Shouldn’t Take Antidepressants
Some doctors are on the fence about this, but more and more bipolar specialists are recommending people with bipolar disorder not take antidepressants. There are lots of reasons for this, and I have to tell you, they are compelling.
Why Shouldn’t People with Bipolar Disorder Take Antidepressants?
Some reasons people with bipolar shouldn’t take antidepressants:
- Antidepressants may not work in bipolar disorder – believe it or not, the literature is mixed on how well antidepressants even work for bipolar depression.
- Antidepressants can induce mania or hypomania (known as switching) – most of us have seen this and it happens all the time to bipolars who are prescribe antidepressants by non-psychiatrists because they just don’t understand the danger. And it is very dangerous because once switched, this type of mania or hypomania can be treatment resistant.
- Antidepressants can induce rapid-cycling or mixed moods – same as above, this cycling can be treatment-resistant.
- Antidepressants can worsen a bipolar’s illness overall – this is more controversial and I suspect varies case by case.
To be clear some people with bipolar disorder will always need antidepressants temporarily, or long term, for their mood, but more and more, doctors are saying to avoid them whenever possible. (Alternatives will be presented in a future article.)
When to Stop Taking Antidepressants
Here are some guidelines from Dr. Phelps about when to stop taking antidepressants in bipolar disorder:
- If they have been on antidepressants a short time, I stop them.
- Less than a week, stop; two weeks, cut in ½, a week later stop.
- Likewise, if they just increased their antidepressants dose I will do the above, decreasing to their previous dose and get rid of the rest later.
- If manic or severely hypomanic, get rid of antidepressants now. Usually can stop abruptly.
- If cycling or mixed get rid of the antidepressants.
- If they are not getting better after several add-on meds then slowly decrease.
- There are more exceptions to the above rules than there are rules.
When to Stay On an Antidepressant if You’re Bipolar
More guidelines from Dr. Phelps: When a bipolar should stay on an antidepressant:
- If the patient is doing well, no mixed state symptoms or cycling, leave it.
- I usually wait until the patient is doing better to much betterto stop an antidepressant; why:
- Trust is an issue. If the first thing we do is make them suffer more they will be unlikely to stay around long and may not even go to another psychiatrist.
- Even though we know the antidepressant is causing harm often time the patient thinks either the antidepressant is helping or every time they try to go off they feel much worse.
- Waiting until they are better is usually a good thing.
- Also waiting longer usually means that the patient is going to be more educated about bipolar in general.
When to Get Off an Antidepressant Recommendations
I think Dr. Phelps’ recommendations are good ones, otherwise I wouldn’t have them here, but note where he says there are more exceptions than he has listed, so keep in mind, you might fall into one of the unlisted exceptions.
And I think the part above where Dr. Phelps talks about trust and making sure the patient is better before messing around with their cocktail is key. It shows he’s respecting the patient and their health, not to mention the doctor-patient relationship which is very important.
Talking to Your Doctor about Getting off Antidepressants is Scary
I know it’s scary to think about going off antidepressants, even if you do think they are causing problems. But think about it, discuss it with your doctor and make the right decision for you. And don’t do anything until you read the next part about how to get off antidepressants without withdrawal.
Bipolar Disorder – Getting off Antidepressant Series
- Bipolar Disorder – When Not to Take Antidepressants
In the final installation of my mixed moods series, I talk about how to treat mixed moods in bipolar disorder. If you need a refresher on mixed moods in bipolar 1 or bipolar 2, see the first three articles in this series:
- Mixed Bipolar Disorder – Mixed Mood Episodes in Bipolar 1
- Mixed Bipolar Disorder – Mixed Mood Episodes in Bipolar 2
- Mixed Moods in Bipolar Disorder and Depression in the DSM-V
Treating Mixed Moods in Bipolar 1 – Mixed Mania
We know most about treating mixed moods in bipolar type 1 as that’s what has been classically defined as a mixed mood in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Because mixed moods in bipolar disorder type 1 are considered a type of mania, one could think of treating them in the same way bipolar mania is treated. Typical mania treatments include:
- Some anticonvulsants
- Antipsychotics (normally atypical)
- Benzodiazepines (for acute anxiety, commonly seen in mania and mixed moods)
Often a combination of an anticonvulsant and an antipsychotic is used.
FDA-Approved Drugs for Treating Mixed Moods in Bipolar 1
Since mixed moods are defined in the DSM, there are specific medications approved by the Food and Drug Administration (FDA) to treat mixed mania. FDA-approved drugs for treating mixed moods in bipolar disorder type 1:
- Carbamazepine extended release (Equetro)
- Aripiprazole (Abilify)
- Ziprasidone (Geodon)
- Risperidone (Risperdal)
- Asenapine (Saphris)
- Olanzapine (Zyprexa)
Why lithium didn’t make the list I’m not entirely sure;* because, as I’ve mentioned, mixed moods and acute anxiety carry a significant risk of suicide and lithium seems to have a particularly strong anti-suicide effect.
Electroconvulsive therapy (ECT) is also indicated for the treatment of bipolar disorder mixed moods.
Treating Mixed Moods in Bipolar 2
As I mentioned in the article on mixed moods in bipolar disorder type 2, mixed moods can either have hypomania or depression as the primary mood. This primary mood then, dictates the type of treatment chosen.
Treating Mixed Hypomania
According to this two-part Psychiatric Times article by Steven C. Dilsaver, MD, mixed hypomania in bipolar type 2 can be treated similarly to treating a mixed mood in bipolar type 1.
Specifically noted is the concern of acute anxiety during mixed hypomania and the fact not all patients readily admit to psychological and physical symptoms of anxiety. However, this is critical information to your doctor and should always be offered, even if not specifically asked.
Other mixed hypomania treatment tips include:
- Comorbid (co-occurring) anxiety may decrease the effectiveness of mood-stabilizing agents, so benzodiazepines may be a better choice.
- Not treating anxiety aggressively can reduce overall long-term treatment outcomes.
Treating Mixed Depression
Mixed depression is particularly hard to treat as mixed moods often predict a lack of response to antidepressants, not to mention the fact that antidepressants can make hypomanic or manic symptoms worse.
A suggested treatment strategy for mixed moods in bipolar 2 with the primary mood of depression is the following:
- Begin by suppressing hypomanic symptoms by using an mood stabilizer or antipsychotic (antipsychotics may work in 1-2 weeks)
- Start medication at low doses and titrate (raise the dose) quickly – this is generally necessary due to the severity of mood symptoms
- If depressive symptoms persist after response to the above medication, add a selective serotonin reuptake inhibitor (SSRI) antidepressant very slowly while watching for signs of hypomania – this requires very close monitoring and likely weekly doctor visits (impossible for some, obviously)
This is very similar to what many doctors are now recommending for bipolar disorder type 2 in general. First, stop the cycling (or hypomania) and see if that also corrects the depression. Avoid the use of antidepressants whenever possible.
Preventing Mixed Depression in Bipolar Type 2
Obviously, no one can guarantee prevention of any mood, but there are some recommendations given in the article, as people with mixed depression are known to be at high risk for reoccurrence.
Tips on preventing mixed depression in bipolar 2 include:
- Lamotrigine is the favorite prophylactic medication as it seems to prevent depression without being an antidepressant
- Ongoing scheduled benzodiazepine doses can help prevent panic attacks^
- A combination of an antipsychotic, plus lamotrigine, plus a benzodiazepine is often “highly effective” (words Dr. Dilsaver’s)
- Lithium is known to be a highly preventative agent; however, in many cases divalproex (Depakote) is superior and has fewer side effects
Series on Mixed Moods in Bipolar Disorder
Whew. OK, there turned out to be a lot to know about mixed moods in bipolar disorder. I hope you learned something reading it as I certainly did writing it.
For your convenience, here are the links to the other three parts in the series:
- Mixed Bipolar Disorder – Mixed Mood Episodes in Bipolar 1
- Mixed Bipolar Disorder – Mixed Mood Episodes in Bipolar 2
- Mixed Moods in Bipolar Disorder and Depression in the DSM-V
Including the Dangers of Using St. John’s Wort to Treat Bipolar Depression
Nevertheless, St. John’s wort is the most well-known alternative treatment for depression and many people take it. However, there are absolutely some dangers in taking St. John’s Wort that you should know about, especially if you’re bipolar.
Warning – the following is information provided by me, a non-doctor. Please check all information out with an actual doctor if you’re at all concerned. Thanks.
St. John’s Wort is not “Safe”
One of the problems with herbal remedies is that people think they are “safe” because they are “natural.” Well, so’s lithium and I wouldn’t recommend chomping on that without a doctor’s supervision either.
Herbs do things. If they didn’t, people wouldn’t take them. St. John’s wort may not be FDA-regulated (a whole other problem) but it is, for all intents and purposes, a drug. This means it should be treated with the same caution as any other drug.
The Diagnostic and Statistical Manual of Mental Disorders (DSM), the manual that defines all mental illness in the US, is being revised and a new version is due out in 2013. One of the proposed changes to the DSM is to the diagnosis of mixed moods. This change is being proposed by a mood disorders workgroup. It aims to reflect clinical practice where doctors already refer to a “mixed” mood that doesn’t officially meet the DSM criteria. (As I noted, mixed moods are only technically recognized in bipolar type 1.)
Changes to the mixed mood diagnosis will help people with bipolar 1, bipolar 2 and unipolar depression get better treatment.
3 Things I’ve Learned About Mental Health This Week
In a continuation of the 3 New Things series, this week follows up on the British Psychological Society’s critique of the Diagnostic and Statistical Manual of Mental Disorders, version 5 (DSM-V), talks about irritable mood in bipolar disorder and expresses my general disdain for people who can’t report about mental health accurately.
1. Do bipolars know when they’re irritable?
Irritability is a symptom for both depression and mania/hypomania in bipolar disorder. This seems to suggest people with bipolar disorder run around biting the heads off of everyone we meet, but this isn’t the case. While I may feel angry and irritable, I, for one, can cover this up as I know it’s a symptom of the illness and not really me.
The interesting thing is, some patients don’t even consider themselves irritable because they have the ability to hide it. Note the following interesting quote:
Patients may not understand what elevated, or euphoric, mood means, so it may be necessary to define these terms. Similarly, the meaning of “irritable” may be unclear to patients. Many patients do not regard themselves as irritable if they can refrain from expressing their easy propensity to anger. Therefore, it is critical to emphasize that although the anger may not be expressed outwardly, the emotion of simply feeling irritable is significant.
From: Psychiatric Times, Mixed States in Their Manifold Forms: Part I
Which begs the question – do you ever consider yourself in an irritable mood? How do you know?
2. The British Psychological Society’s Critique on the DSM-V
Last week I asked if the British Psychological Society (BPS) was reputable as I questioned the motives behind their critique of the DSM-V revisions. It’s not that they don’t have their points, it’s just the points they’re making are copied-and-pasted to virtually every diagnosis either new to the DSM or not. It turns out my suspicions may have been wrong. The BPS does seem to be a genuine, reputable organization.
I came across an article in Psychiatric Times that explained issues with the BPS’s DSM-V critique beautifully – by blindly applying the same “feedback” to virtually every part of the DSM, their feedback has no weight at all and smacks of an agenda.
Even if they say something people should be listening to, it gets lost in the din of all the noise caused by putting the feedback where it doesn’t belong (article).
3. Reporting on Mental Health Issues is Appalling
I am not a reporter. I try to be a true, honest, accurate writer of credibility, but a reporter I never claimed to be. For actual reporters though, I rather think they have a higher bar.
Like, to write things that are accurate. Exhibit A:
The treatment [rTMS] hinges on the idea that every cell in the body has an electromagnetic field, and when this field is out of alignment, problems develop. RTMS then uses the highly focused magnets to realign a depressed person’s brain, and get it functioning properly again.
For the record, that is incredibly wrong and rather stupid. rTMS has nothing to do with cells having “electromagnetic fields” and there is no such thing as “realignment.” That all sounds like new age mumbo-jumbo which, in this case, takes actual science and turns it into nonsense. All I can say is that if you read something in the media, you’d better check out the facts yourself because it sure seems like the reporter isn’t going to bother.
rTMS uses a very strong, magnetic field that rapidly changes polarity to create an electrical current. This current activates neurons in a specific part of the brain just like electroconvulsive therapy, but without the cognitive side effects (or likely, effecacy rate).
Perhaps it’s too much to ask that a reporter understand those two sentences. Sheesh. (And for an extra dose of outrage, check out the comments, which can only be inflamed by the misinformation in the article.)
Until next week when I will learn more and try to do better.
As I mentioned, mixed moods are technically considered part of the manic phase of bipolar disorder and thus, by definition, are only a part of bipolar disorder type 1. However, those of us with bipolar type 2 can tell you we mix it up with the best of them.
So, in part II of this series on mixed moods in bipolar disorder, I look at mixed moods in bipolar type II.
Ask a Bipolar – What is a mixed mood in bipolar disorder?
As one of the Burble’s commenters mentioned, there seems to be a lack of good information on mixed moods available. After some Googling, I would tend to agree. While mixed mood episodes are pretty common for us bipolar folk, few people seem to be discussing it.
This is the beginning of a four-part series on mixed moods in bipolar disorder:
- Mixed Mood Episodes in Bipolar Type I
- Mixed Mood Episodes in Bipolar Type II
- Changes to Mixed Mood Episode Diagnosis in the Revision of the DSM
- Treating Mixed Mood Episodes
What is a Mixed Mood Episode?
By definition, a mixed mood in bipolar disorder is the presence of both depression and mania. According to the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), mixed moods are only present in bipolar disorder type 1 as mixed moods require the presence of mania.
Mixed mood episodes are (officially) found in bipolar disorder 1 and are characterized by:
- Persons must meet both the criteria for mania and major depression; the depressive event is required to be present for 1 week only.
- The mood disturbance results in marked disruption in social or vocation function.
- The mood is not the result of substance abuse or a medical condition.
Mixed mood episodes are officially considered part of the manic phase of bipolar disorder.
As requested, I’m going to provide the details on the custom mood / variables I use in the T2 Mood Tracker. These are just my variables, they certainly don’t have to be yours, but they might be good to glance over.
Custom Moods / Variables I Use to Improve Mood Tracking
As I mentioned, the more difficult a case you are, and boy am I difficult, the more challenging the patterns can be to find. This is why I’ve included these extra variables. Custom moods / variables include:
OK, you’ve sold me as to why I should track my mood (part 1); so just how do I track my mood?
Obviously, the simplest form of mood tracking is just recording depression and mania on a scale, say, of one-to-ten. You could use a “paper” and “pencil” (look it up on Wikipedia).
You might still notice mood trends but that type of mood tracking is not nearly as helpful as it could be. And the more complicated your case, the more you already know, the more subtle your shifts may be and the less you’ll see using simple methods.
There are far more useful, not to mention easier, options.
If you’ve been around for the last couple of weeks either at the Burble or at Breaking Bipolar, you know it’s been pretty much all suicide all the time. And there will probably be more to come on suicide as it’s an awfully big topic.
But I do have a question for everyone:
What topics would you like to see on the Burble?
Are there questions about me? Bipolar? Mental illness in general? A timely topic?
A reader recently suggested a topic on mental illness and euthanasia / right to die. A great idea. (Although really hard. Someone is clearly wanting me to tackle a rather large challenge.)
I can’t promise I’ll address all your questions / suggestions, but I would like to hear them nonetheless. Because if there’s one thing I’ve learned by writing the Burble for so long: Readers will surprise you.
So, you have the microphone. What mental health topics are you thinking about?
In part one I discussed the details of a study about 100 people who attempted suicide in Florida. Part two outlines the predictive factors for suicide attempts identified in this study and how we can use this information to predict who will attempt suicide.
And perhaps more importantly, how you can prevent a suicide attempt in a loved one.